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Wednesday, May 29, 2019

Retrospective #103: Your Mileage May Vary (YMMV)

Your Mileage May Vary (YMMV) is an expression
that I didn’t put much stock in when I first read it years ago on a Low Carb
Forum. I was a neophyte in the self-management
of my Type 2 diabetes, even though I had been a Type 2 for 16 years. Up until
then, like most of us, I had left my health care in the hands of my physician.
So, in those early days of self-management – if I thought about it at all, I thought
that we Type 2s were all pretty much alike.

What prompted me to write about this [in 2013] was
a personal experience I had with my blood sugar (BS) control. My most recent
A1c was 5.6%. It’s been better and, of course, worse. I had been eating a
restricted-calorie, Very Low
Carb (+/-15g) ketogenic diet for several months to lose weight and had lost 25
pounds. Five consecutive daily fasting blood glucose readings averaged 90mg/dl,
with a tight range. Then, at a small dinner party in our home, I ‘blinked’ (transgressed):
I had about a cup of risotto (with Osso Bucco and broccoli rabe) and some dessert
(2 homemade cookies and 2 bouillon-cube sized petit fours). My body hadn’t had
this much starch and sugar in a long time, and it was not prepared for it. My fasting blood glucose the next
morning was 120mg/dl. The next day my FBS was still 117. The next day 114, the
next 123, and so on. I had fallen off the ketogenic cliff and had lost BS control.

That’s where YMMV comes in. It depends on your
medical history (both the type and degree of metabolic dysfunction and when and
how you and/or your doctor responded to the discovery that you were Pre-diabetic
or a diagnosed Type 2. I was diagnosed in 1986. The first thing my doctor did,
besides advising me to lose weight (“eat less on a ‘healthy’ balanced diet”), was to prescribe a sulfonylurea(SU), a class of
oral anti-diabetes medication that makes the pancreas produce more insulin. At
the time, sulfonylureas were the only
oral anti-diabetes medication prescribed in the U. S. When I continued
to eat carbohydrates, and the SU didn’t get my BS under control, my dose was
increased until I was ‘maxed-out’ on this med. Then, when Metformin was
approved for use in the U. S., I started on and eventually was maxed out on it too
and started on a 3rd oral med. On a “balanced” diet, however, my blood sugar continued to elude control,
and my Type 2 diabetes inexorably
progressed.

My Type 2 diabetes didn’t stop its progression until
I changed my diet. In fact, it reversed to the point of being undetectable as long as I “eat right”
(VLC). After starting to eat Very
Low Carb (VLC), in the first week I forced to take fewer and fewer oral anti-diabetic
meds. Still, it was almost five years before I completely titrated off the SU,
so I took an SU at some dosage level for 21 years. So, I wondered, what effect
did this have on my pancreas?

Well, I’m not a doctor, so I’ll refer instead to
what one of my favorite diabetes specialists, Ralph A. DeFronzo, M.D., has been
saying for years. In his Banting-award lecture at the 2008 Annual Meeting of
the American Diabetes Association in San Francisco, Dr. DeFronzo said, “By the
time that the diagnosis of Diabetes is made, the patient has lost over 80% of
his/her β-cell function.” He also said in the first paragraph of the full-text
article published by the ADA on the NIH website, “Sulfonylureas are not
recommended because, after an initial improvement in glycemic control, they are
associated with a progressive rise in A1c and a progressive loss of β-cell
function.”

So, where does this leave me? If I had lost over
80% of my β-cells upon being diagnosed, and continued eating a “balanced” diet (with
lots of carbs) for another 16
years, my pancreas still needed to make insulin with fewer β-cells. The SU continued
to push it to do that because the goal
was to control my blood sugar with medications.

So, a disease that starts with insulin resistance
progresses to pancreatic β-cell burnout as it responds to that resistance. That is inexorable if you don’t dramatically
change your diet. It will likely accelerate if you continue to use a sulfonylurea to get your pancreas
to pump insulin. That is the “course of action” of the disease. That course will
be inexorable if 1) you don’t
change your diet and 2) you don’t stop taking a sulfonylurea. You must
do both to protect and preserve what pancreatic β-cell function you
have left before it’s too late.
If you choose to do both 1)
and 2) when you are at an early stage
of this disease, YMMV from mine. If you don’t, like me, you may become
totally carbohydrate intolerant. And like me, you will not be able to “cheat” from time to time and get away with
it.

About Me

I was diagnosed a Type 2 diabetic in 1986. I started a Very Low Carb diet (Atkins Induction) in 2002 to lose weight. I didn’t realize at the time that it would put my diabetes in clinical remission, or that I would be able to give up almost all of my oral diabetes meds. I also didn’t understand that, as I lost weight and continued to eat Very Low Carb, my blood lipids would dramatically improve (doubling my HDL and cutting my triglycerides by 2/3rds) and that my blood pressure would drop from 130/90 to 110/70 on the same meds.
Over the years I changed from Atkins to the Bernstein Diet (designed for diabetics) and, altogether lost 170 pounds. I later regained some and then lost some. As long as I eat Very Low Carb, I am not hungry and I have lots of energy. And I no longer have any of the indications of Metabolic Syndrome.
My goal, as long as I have excess body fat, is to remain continuously in a ketogenic state, both for blood glucose regulation and continued weight loss. I expect that this regimen will continue to provide the benefits of reduced systemic inflammation, improved blood lipids and lower blood pressure as well.